Spring Vision Quest 2017

Fay Jobe Tripp, MS, OTR/L, CDRSLCI Vision Rehabilitation Services

Occupational Therapy Duke Eye Center, Duke Health System

¡ Increase knowledge of compensatory strategies and devices to maximize function and safety.

¡ Increase awareness of new technologies for vision enhancement.

¡ Increase awareness of available resources for vision impairment.

¡ World Health Organization (2007)World Health Organization; “ Vision 2020: The Right to Sight”. 2007.http://www.who.int/blindness/Vision2020_report.pdf

§ 161 million people worldwide have vision impairment

§ 124 million people worldwide have low vision

§ The number of people with partial sight is expected to be nearly 7.9 billion by the year 2020.

¡ American Academy of Ophthalmology support: https://www.aao.org/low-vision-and-vision-rehab

The Academy's Initiative in Vision Rehabilitation“Referring low-vision patients (those with visual acuities less than 20/40 or scotomas, field loss or contrast loss) to vision rehabilitation services connects them with services that lessen the impact of their vision loss, and improves their independence and quality of life.

¡ Early intervention supports maximal function, quality of life, safety and emotional health (decreased depression)

¡ Legal blindness : § best corrected acuity 20/200 or less in better seeing eye§ Visual field limitation < 20 degrees

¡ Ophthalmologist or optometrist

¡ Optical assistant, technician, medical technologist

¡ Low-vision specialist or therapist (CLVT)

¡ Occupational therapist

¡ Rehabilitation teacher

¡ Orientation & mobility specialist

¡ Social worker

¡ Counselor

¡ Device vendors and trainers

Occupational therapy: https://www.aota.org

¡ Focuses on reducing the impact of disability by promoting maximal independence and participation in valued activities.

¡ Practitioners use the term “occupation” to represent activities that individuals need and/or want to do and that are meaningful to them.

¡ Is celebrating our profession’s 100 year anniversary!

¡ Vision impairment can greatly impact a person’s quality of life, ADL and Instrumental ADL independence and safety in the home and community.

¡ Many geriatric clients seen for visual impairments have co-morbidities that may significantly expound overall functional ability and safety.

¡ Using simple, practical techniques and modifications can be performance changing, improve functional outcomes and improve safety.

¡ These evidence based treatment strategies may easily be added to your clinical tool kit, and be easily integrated into your team’s clinical practice, even if only through client conversation.

¡ Congrats for choosing a profession that enables you to have a great impact on your clients’ lives !§ Visual impairment has been identified as one of the four

most significant contributors to the loss of independence among older Americans. (Alliance for Aging Research, 2009)

§ ADLs and IADLs§ Home and Community§ Leisure and Work

§ Practical, affordable§ Appropriate to learning level

¡Refractive Errors—updated prescription for glasses or contacts

¡Cataracts—blurring, decreased detail, sensitivity to bright light and glare, decreased contrast sensitivity

¡Glaucoma—”thief of sight”, decreased peripheral vision, decreased night vision

¡Age Related Macular Degeneration—decreased central vision / detail; peripheral vision is better ; younger of Stargardt’s Disease

¡Diabetic Retinopathy—mild to severe loss; affects approx 30% of diabetic patients

¡Corneal Opacities—eye injury, infection or certain eye diseases that lead to scarring or clouding of the cornea (chemical, radiation, contacts)

¡Retinitis Pigmentosa (RP)—peripheral vision gradually declines into tunnel vision; commonly progresses to no vision.

According to World Health Organization: “ Vision 2020: The Right to Sight” 2007.

RetinitisPigmentosa-tunnel vision-dim light difficulty-poor light adaptation-light sensitivity

Cataracts -blurring -decreased detail-bright light and glare tolerance-poor contrast sensitivity -faded colors

Glaucoma -“thief of sight” -loss of peripheral vision-decreased night vision

Macular Degeneration-decreased central vision-scotoma -poor detail-better peripheral vision

Diabetic Retinopathy -blurring -poor detail-spots, floaters-fluctuating vision

https://www.nei.nih.gov/health/National Institutes of Health

Common refractive errors related to visual acuity :Myopia—near-sighted; blurry distance vision Hyperopia—far-sighted; blurry near vision Amblyopia—lazy eye; poor depth perceptionPresbyopia—aging eye condition; poor near focus

¡ Neurological§ CVA/stroke, cerebellar atrophy or degeneration§ Brain tumor§ Brain injury, traumatic optic nerve damage§ Optic nerve atrophySymptoms:

▪ homonymous hemianopsia, quadranopsia▪ optic nerve damage with decreased acuity and field▪ diplopia, double vision

¡ Parkinson’s Disease, Parkinsonism§ Diplopia, double vision§ Decreased motor control § Blepharospasms§ Dry Eye issues, decreased blink rate§ Possible impaired depth perception

¡ Multiple Sclerosis§ Optic neuritis§ Blurriness, decreased acuity, individual or OU§ Impaired motor control § Impaired endurance with increased fatigue § Vision may fluctuate

¡ Myasthenia gravis § Impaired motor control§ Diplopia, double vision§ Decreased depth perception

¡ Acquired Monocular Vision Loss§ Significantly decreased acuity in one eye§ Decreased peripheral vision§ Decreased depth perception

▪ Eye-hand coordination impairment with grasping errors▪ ADL, IADL task difficulty▪ Huge fall risk in functional mobility: stairs, curbs▪ Driving safety issues

What can we teach our clients to

maximize visual function ?

“Don’t BLOCC my vision.”VA LOVIT: Veteran's Affairs Low Vision Intervention Trial, 2007

Joan Stelmack, OD

¡ Brightness— increase contrast, light <-> dark

¡ Lighting—use task lighting, decrease ambient light, glare control

¡ Object Size—magnify, use larger print, adaptations

¡ Contrast—clear bright contrasting colors, fluorescent marking

¡ Clutter—visually too busy, keep it visually simple

¡ Brightness and increased contrasthttp://www.visionaware.org/info/everyday-living/home-modification-/contrast-and-color/125

Light ß à Dark

Bright ß à Neutral

http://www.visionaware.org/info/everyday-living/home-modification-/room-by-room/kitchen/low-and-high-contrast-kitchen/12345

http://www.visionaware.org/info/everyday-living/home-modification-/room-by-room/kitchen/low-and-high-contrast-kitchen/12345

¡ Examples§ Tab markers, tactile dots on appliances§ Mark bottles with tape, rubber band§ Medication management with dark hand towel,

pill box organizer with contrast color§ Highlight cabinet corners or doorways § Highlight shower or tub edges, grab bars§ Plates, cups with contrasting color: dark food on

white plate; white food on dark plate

Waterproof bright tape, Hi Marks tactile paints,Velcro strip and dots, soft Touch Dots

http://www.visionlossandpersonalrecovery.com

¡ Compensatory writing strategies§ Large print materials§ Large lined, tactile notebooks§ Writing guides, larger size§ Large print calendars§ Bold markers, 20/20 Papermate

§ Full spectrum lighting▪ Blue light reduction for reduced glare▪ Watts; lumen or lux : 2200+ for reading▪ Brands: Ottlite, Verilux, Daylight, Chromolux

§ Task directed▪ Focus lighting on task▪ Reduce ambient light▪ Control glare: close shades, reposition monitor

§ Sun Filters▪ Blue light blocker: pilot or hunting glasses▪ Non-polarized▪ Wrap-around, Fit-overs, Slip-ins▪ Brands: Cocoons, Solar Shield, NoIR

Ottlite with mag

Verilux Easy Flex

¡ Magnification § Magnifier considerations

▪ Power (ex: 5X )▪ Diopter (ex: 20 D)▪ Illumination ▪ No illumination

§ Other magnifier considerations▪ The higher the power, the closer the working distance.▪ The higher the power, the smaller the field of view.

¡ Magnifiers§ Hand held § Slide out pocket§ Stand magnifiers§ Globe, Dome § Max Detail, Max TV

¡ Electronic Video Magnifier: portable

Scientific Freedom Ruby XL HD, Ruby

Enhanced Vision Pebble, Pebble Mini Eschenbach

Smartlux Digital

¡ Electronic Video Magnifier: desk § Desktop or portable (CCTV—closed circuit television)§ Magnifies the image to the screen§ Reversed mode or color for increased contrast§ Brightness control § Photo or freeze frame § object character recognition (OCR),

speech to text

Magnilink S, near/far, text to speech, portableFreedom Scientific Topaz XL HD

Enhanced Vision DaVinci, OCR, portableOptelec ClearView + Speech OCR

¡ Miracle Mouse Electronic Reading Aid¡ Wireless or wired¡ Works through digital TV or computer monitor

¡ Accessibility features: Windows, Apple systems§ Magnifier, Zoom § Contrast, invert colors § Narrator, Voice over functions

¡ ZoomText 10.1, ZoomText Mac,ZoomText Express

¡ Keyboards§ Contrast: zoom caps§ Tactile cues: tabs, velcro

MAGIC®A solution for low vision computer users to help you work more efficiently with business applications, documents, email, Internet, and social networking.

JAWS®A screen reader, developed for computer users whose vision loss prevents them from seeing screen content or navigating with a mouse.

¡ Object Character Recognition (OCR) / Text to Speech Devices§ Optelec ClearReader + Speech

§ Enhanced Vision Smart Reader

§ Sara—Scanning and Reading Appliancehttp://www.freedomscientific.com/products/lv/sara-product-page.asp \

¡ Smart phone Apps: Apple and Android ▪ Camera use for text to speech function

▪ KNFB reader (Kurzwell National Federation for the Blind)▪ Text Grabber

▪ TapTapSee: object picture recognition ▪ VisWiz and BeMyEyes: remote sighted person gives details▪ Magnifiers: Brighter & Bigger; SuperVision Mini ▪ Flashlight : use built in light▪ Eye Note: recognizes money▪ Color ID: recognizes color

¡ Apps and downloads ▪ Accessibility features: text size, contrast, zoom▪ Voiceover, Talkback▪ SIRI , Google S Voice performance

¡ Additional Apps: § Braille Institute—VIA (Visually Impaired Apps): recommends

other apps specific to individual’s needs for low visionhttp://brailleinstitute.org/programs/index.php/digital/mobile-applications

¡ Lighting¡ Glare control and contrast ¡ Acquired Monocular Vision Loss issues¡ Stairs

§ first step and last step § ascending or descending

¡ Curbs: glare, decreased contrast ¡ Bathrooms: showers and tubs

Mobility aid use

Appropriate lighting and contrast

Guide dogs

Marked pathways with tactile info

¡ Bioptic Telescope Lens System (BTLS)§ Monocular

▪ Ocutech VES Sport▪ Spot reading▪ Board, signs▪ Common for driving

§ Binocular ▪ Beecher Mirage▪ Ocutech SightScope▪ Distance, TV, Board

§ Driving applications▪ Spot checking only▪ Decreased field of view

VES SportOcutech

SightScopeOcutech

Beecher Mirage

¡ NC DMV Medical Review requirements § Ophthalmologist or OD recent exam report

▪ Visual acuity with carrier lens and BTLS▪ Visual field test—horizontal with degrees

▪ Prefer Goldmann Visual Field Test (III4e)▪ Discussion of including vertical visual field measurement

§ Visual acuity (NC General Assembly: G.S. 20-7)▪ 20/200 or better in one or both eyes with or without corrective

carrier lens▪ At least 20/70 with BTLS in one or both eyes, without field

expanders▪ Visual Field -- horizontal vision

▪ Binocular vision: 70 degrees ▪ Monocular vision: 40 degrees temporal; 30 degrees nasal

¡ BTLS Training components § “Pre-Driving Readiness” clinical training § “Descriptive passenger driver” in car as passenger§ Behind-the-wheel training with certified driving

instructor

¡ Common restrictions§ No night driving§ No interstate§ Self-restrictions

¡ Second Sight Argus II Retinal Prosthesis§ http://www.2-sight.com/§ Retinitis Pigmentosa

¡ IMT : Implantable Miniature Telescope § www.centrasight.com§ http://pubs.aarp.org/aarpbulletin/201503_DC?p

g=31#pg31§ Macular degeneration

¡ NuEyes wearable prosthesis technology§ https://nueyes.com/§ Smart glasses technology; ODG§ Android based tablet

§ Speech to text reading

¡ E-Sight 3 technological eyewear§ http://www.esighteyewear.com/

¡ OrCam MyEye § http://www.orcam.com§ Wearable auditory visual device § Text to speech/ OCR§ Knows learned faces§ Knows learned objects § Mounts on temple of own glasses

¡ Blind Rehabilitation Outpatient Clinic (BROC)§ Multiple locations across NC, SC, Virginia§ Durham Veterans' Administration

▪ Contact:▪ 8081 Arco Corporate Drive, Suite 120, Raleigh, NC 27617▪ Phone: 919-286-5235▪ http://www.durham.va.gov/locations/BlindRehab.asp▪ Services Available: Blind Rehabilitation and Visual Impairment

Services▪ Facility features: State of the art facility includes training kitchen, tele-

health capability, visual skills room, computer training room, electronic aid room

§ www.independentliving.com

§ www.maxiaids.com

¡ http://www.eschenbach.com/

¡ http://freedomscientific.com/

¡ https://us.optelec.com/

¡ https://www.enhancedvision.com/

¡ http://www.aisquared.com/ Zoom Text and Mac, Zoom Text Express

¡ http://www.esighteyewear.com/ E-sight Technological Eyewear

¡ http://www.2-sight.com/ Argus II Retinal Prosthesis

¡ http://www.orcam.com/ OrCam MyEye Wearable vision device

¡ https://nueyes.com/ NuEyes wearable prosthesis

¡ American Foundation for the Blind http://www.afb.org/default.aspx

¡ Vision Aware http:// www.visionaware.org/

¡ Foundation for Fighting Blindness http://www.blindness.org/

¡ American Printing House for the Blind http:// www.aph.org

¡ National association listing http://www.lowvision.org/national_associations.htm

¡ E.A.R.S. for EYES (ADL/IADL CD) http:// www.earsforeyes.org

§ NC resources§ Division of Social Services for the Blind http://www.ncdhhs.gov/dsb/services/§ Governor Morehead School for the Blind http://www.governormorehead.net/§ NC Assistive Technology Exchange Post http://www.ncexchangepost.org/home.php§ NC Lion’s Club http://nclionsinc.org/

§ VA Blindness Rehab Out-patient Clinic http://www.durham.va.gov/locations/BlindRehab.asp

¡ http://www.covd.org

¡ http://www.oepf.org

¡ http://www.visiontherapy.org

¡ http://www.vision3D.org

¡ http://www.optometrists.org

¡ http://www.add-adhd.org

¡ http://www.visiontherapystories.org

¡ http://www.childrensvision.org

¡ http://www.braininjuries.org

¡ http://www.eyecanlearn.com/

Thank you !

Duke Eye Center: Hudson Building LCI Vision Rehabilitation Clinic